LUTHER PARK 2008 PROGRAMMED RETREATS REGISTRATION & HEALTH FORM

Name ____________________________Grade____ Sex___ Birth date (optional for adults) __________E-mail _________________

Name ___________________________ Grade____ Sex___ Birth date (optional for adults) __________E-mail _________________

Name ___________________________ Grade____ Sex___ Birth date (optional for adults) __________E-mail _________________

Choose retreat(s) you want to attend:

___ Ice Fishing, Jan. 18-20, 2008 ($60 for ages 13+, $30 for 5-12, an adult must accompany those under 18)
___ Sr. High Leadership Retreat, April 4-6, 2008 (Free to 2007 LTS, LMS, & TIMS; $60 for previous participants)

___ Junior/Senior High, Apriil 11-13, 2008 Grades 6-12 ($60)

___ Elementary Retreat, April 4-6, 2008 Grades 3-5 ($60)

The cost for each weekend includes food, lodging and programming. Bring warm clothes, sleeping bag, toiletries, Bible, and lots of energy and excitement. Retreats begin at 7:00 p.m. on Friday and end at noon on Sunday unless otherwise noted.

A deposit for half the total amount is required with registration.

Total fee: $________ Deposit enclosed: $____________

Congregation_________________________________________________
Name of one cabin mate ____________________________________

Custodial Parent(s)Guardian(s)________________________
Address ______________________City _______________ State ____ Zip____
Home Phone____________________ Work Phone __________________

INSURANCE INFORMATION:

Policy Holder__________________________________________ Soc. Sec.#_____________________________________
Employer _________________________________Insurance Co._____________________
Insurance Co. Phone #_______________________________________________________
Insurance Co. Address _______________________________________________________________________________

Birth date of Policy Holder _____________________Group No. __________________Policy/ID No.________________

Family Doctor and Phone # ___________________________________________________________________________

Emergency Contact: _______________________________________

Emergency Phone: ________________________________________

HEALTH HISTORY & PARENT/GUARDIAN AUTHORIZATION

THIS SECTION MUST BE COMPLETED AND SIGNED BY PARENT/GUARDIAN

My child has permission to engage in all camp activities, except as noted by the examining physician and myself. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, to order injection, anesthesia or surgery for my child named above. I voluntarily waive any claim against the sponsoring institution, local churches and camp personnel for any mishap or lost articles, or any and all causes which may arise in connection with activities of the above organization. I understand that unless I provide separate written notice, photos taken of my child at camp may be used for camp-approved publications such as the Luther Park Echoes.

Please list ALL allergies & medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire weekend. Keep in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. For everyone's safety ALL medications brought to camp including prescription, over-the-counter, medicated creams and ointments will be kept in the Health Center.

Allergies________________________________________________________________

Medications_____________________________________________________________

Signed________________________________ /________________________________

Camper Parent

Date _____________________________